Basic Information
| Provider Information | |||||||||
| NPI: | 1871881169 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | JED | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 281 SANDERS CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130571307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154546000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 834 W JOHNSON ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549352018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209297400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2011 | ||||||||
| LastUpdateDate: | 07/20/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 5749 | WI | Y | Dental Providers | Dentist | General Practice |
No ID Information.